NCC231033_FRO Submitted_20230417

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered LV �
form and an acceptable erosion and sedimentation control plan have been compke o r
the Land Quality Section, N.C. Department of Environmental Quality. Submit the c
appropriate Regional Office. (Please type or print and, if the question is not applicable or the e-mail and/
or fax information unavailable, place NIA in the blank.)
Part A. WCCA Daycare Center
1. Project Name y
2. Location of land-disturbing activity: County Polk City or Township Columbus
Highway/Street White Drive Latitude 35.2504 Longitude-82.20425
3. Apbroximate date land-disturbing activity will commence: upon approval
4. Purpose of development (residential, commercial, industrial, institutional, etc.):commercial
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 1 .2 acres
6. Amount of fee enclosed: $ 200.00 The application fee of$100.00 per acre
(rounded up to the next acre) is assessed without a ceiling amount (Example: 8,10 ac = $900.00).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name David W. Odom, P.E. E-mail Address [e-mail]
Telephone [phone] cell# 828-429-4355 Fax# NIA
9. Landowner(s) of Record (attach accompanied page to list additional owners):
Western Carolina Community Action, Inc. 828-693-1711 828-697-4277
Name Telephone Fax Number
P.O. Box 685 220 King Creek Road
Current Mailing Address Current Street Address
Hendersonville NC 28793 Hendersonville NC 28792
City State "Zip City � State Zip
10. Deed Book No. 463 Page No. 2462 Provide a copy of the most current deed.
Part B.
1. Company(ies) or firm(s) who are financially responsible for the land-disturbing activity (Provide a.
comprehensive list of all responsible parties on an attached sheet.) If the company or firm i
the name of the owner or manager may be listed as the financially responsible party. 's
Western Carolina Community Action, Inc, [e-mail]
Name E-mail Address
P.O. Box 685 220 King Creek Road A ,IJPVHI �.
Current Mailing Address Current Street Address
Hendersonville NC 28793 Hendersonville NC 28792
City State Zip City State Zip
Telephone [phone] Fax Number 828-697-4277

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
David White [e-mail]
Name of Registered Agent E-mail Address
P.O. Box 685 220 King Creek Road
Current Mailing Address Current Street Address
Hendersonville NC 28793 Hendersonville NC 28792
City State Zip City State Zip
Telephone [phone] Fax Number 828-697-4277
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein. %p�
R�"'��F I F )
David White Registered Agent
Type or print name Title or Authority
"i:j l Lure D to �>rT Trrrr�
I, t'r 6 sA a Notary Public of the County of �lctilr prst��l
State of North Carolina, hereby certify that A u � (A appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this l-) day of_12f 0 e 1)•' 11-e r , 20��
KIMBEriLY C HALL
Notary Public, North Carolina + -
Henderson County Notyn
My,b"nission Expires
February03,2o2s My commission expires